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Since 2004, multiple blockbuster drugs have been approved for men with metastatic prostate cancer. Nevertheless, it has been reported that no improvement in survival was observed between 2004 and 2009. Herein, we have analyzed the SEER database to assess the survival outcome of metastatic prostate cancer patients since 2000. The results demonstrated that there was an improvement in both overall and prostate cancer‐specific survival for 4 months among men diagnosed with metastatic prostate cancer from 2010 to 2016 when compared to those in the pre‐2010 period. Interestingly, this survival benefit was limited to patients with bone and visceral metastasis (M1b and M1c stages). Collectively, our observation suggests that despite the new treatment agents such as second‐line antiandrogen therapies introduced in the modern era, the improvement in survival of metastatic prostate cancer patients has been surprisingly small., Since 2000–2003, there has been an improvement in both overall and cancer‐specific survival of only 4 months in men diagnosed with metastatic prostate cancer.

MicroRNAs (miRNAs) are small noncoding RNAs involved in the regulation of mRNA transcription and translation, and possess all desirable features of an ideal tumor marker. Of almost 31 different miRNA clusters identified in germ cell tumors (GCTs), miR-371a-3p has shown exceptionally high sensitivity and specificity for both seminomatous and nonseminomatous GCTs. It is easily obtainable and correlates well with tumor burden. Recent multi-institutional prospective studies have shown promising test characteristics for miR-371a-3p as a diagnostic blood-based biomarker for GCT prior to orchiectomy including 80%–100% sensitivity and 90%–100% specificity. This accuracy may address other unmet needs in the management of patients with GCT. Early studies have suggested the utility of miR-371a-3p in detecting occult nodal metastasis in high-risk clinical stage I and early stage II disease. Ongoing clinical trials including SWOG 1823 and AGCT1531 are specifically designed to confirm the utility of miR-371a-3p in clinical stage I GCT. Despite its strong association with viable GCT after treatment with chemotherapy, miR-371a-3p does not seem to accurately predict the presence of teratoma in residual lesions. Also, standardization of extraction and interpretation methods is a necessary step to assure uniform results across different institutions.

OBJECTIVE To assess both short- and long-term constipation symptoms and their impact on quality of life in patients who underwent radical cystectomy (RC) with three different types of urinary diversion: orthotopic neobladder (ONB), continent cutaneous diversion (CCD), and ileal conduit (IC). MATERIALS AND METHODS The validated Patient Assessment of Constipation Symptoms (PAC−SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires were administered to all patients at follow-up greater than 30 days from surgery. Clinical and pathological characteristics were prospectively recorded in an institutional review board approved bladder cancer database. Using multivariable linear regression analyses, we determined significant predictors of improved constipation symptoms and quality of life scores. RESULTS A total of 198 patients completed 255 PAC−SYM and PAC-QOL questionnaires with a median follow-up time of 1.7 years (IQR: 0.7 – 3.0 years). ONB, CCD, and IC were performed in 78%, 5.5%, and 16.5% of patients, respectively. Higher bowel function scores (i.e. worse symptoms) were noted at 3 months post-operatively, while these scores significantly improved over time for PAC-SYM total score (P = .004), abdominal subscore (P = .001), and rectal subscore (P = .018). On multivariable analysis, we found that patients 1 year (B -4.8, P = .001), and who received an IC (B -2.4, P = .02) had significantly lower PAC-SYM scores. CONCLUSION Patients have few constipation symptoms and are overall satisfied with their bowel function at long-term follow-up after RC. While patients with IC have significantly fewer constipation symptoms compared to those with ONB or CCD, all patients had significant improvement one year after the surgery.

Objectives To evaluate the risk of occult nodal metastasis in patients with muscle invasive bladder cancer who exhibit a complete or partial clinical response to neoadjuvant chemotherapy (NAC) and assess a potential role for “bladder sparing” management given that the gold standard treatment, radical cystectomy (RC), is associated with high morbidity. Methods We queried the National Cancer Database for bladder cancer from 2004 to 2013 including patients with cT2-4aN0M0 bladder cancer who underwent multiagent NAC followed by RC and pelvic lymphadenectomy and excluding patients with nonurothelial predominant histology and those undergoing partial cystectomy. Student's t test was used to evaluate patients’ demographics, presence of co-morbid conditions, and pathologic findings, notably the presence of lymphovascular invasion and variant histology. Results We identified 17,917 patients who underwent RC. Of these, 14.9% (n = 2673) received NAC before RC. About 13.1% and 14.5% of patients had complete (ypT0) and partial (ypTa, Tis, and T1) pathologic response, respectively. These 14.7% of cT2, 9.0% of cT3, and 6.9% of cT4 patients exhibited pT0 status on final pathology. And 4.9% of complete and 5.4% of partial responders demonstrated occult nodal metastases. Age, sex, ethnicity, the presence of co-morbidities, LVI, and variant histology were not significantly associated with occult nodal metastasis. Conclusion While bladder preservation may be a viable option in patients who are carefully selected and closely followed after NAC, patients undergoing NAC may be at risk of occult disease outside of the bladder despite an otherwise clinical complete response diagnosed with cross-sectional imaging, cystoscopy, TURBT, and cytology.

Objective: To present a case series of urethro-cavernosal fistulas evaluating their diagnostic work-up and management. Methods: A literature search was performed using key words including “urethro-cavernosal fistula,” “urethral fistula,” and “cavernosal fistula.” Results: In total 10 case reports were identified and reviewed for information regarding clinical diagnosis, management, and long-term outcomes including success rates and complications. Conclusion: Urethro-cavernosal fistula is a rare urological condition. With few cases reported to date, there is considerable variation in diagnostic work-up and management. Both conservative and surgical approaches can be utilized in the management of urethro-cavernosal fistulas with good long-term outcomes. Level of evidence: Not applicable for this multicentre audit.

Background The perception of penile length loss is common in male patients undergoing radical prostatectomy; however, this has not been described after radical cystoprostatectomy (RC). Aim To evaluate perceptions of penile length loss in male patients after RC and contributing factors. Methods Patients completed an institutional review board–approved questionnaire comprised the International Index of Erectile Function (IIEF-5) and supplemental questions including perceived changes in penile length after RC. Multivariable analysis was performed to determine associations between the perception of penile length loss and the amount of length lost with patient and surgery-specific factors. Outcomes The rate of patient-reported penile length loss and factors contributing to this perception was the outcome of this study. Results From October 2017 to January 2019, 151 patients completed the questionnaire. The median age at cystectomy was 66.1 years (interquartile range [IQR]: 59.4–73.3), and the median duration of follow-up was 28.3 months (IQR: 13–74.1). Preoperative IIEF-5 was available in 55 patients with a median score of 14 (IQR: 3–20). The median IIEF-5 score at time of survey completion was 3 (IQR: 1–18). The majority of patients (55.1%) reported a perceived loss of penile length, 20.4% reported no loss, and 24.5% were unsure. Of those who quantified their loss in penile length, 54.6% reported losses of an inch or more. Neurovascular preservation was not found to protect against penile length loss but did correlate with a reduction in the amount reported lost (P = .008). Multivariable logistic regression analysis identified increasing IIEF-5 score at time of survey completion to protect against a perceived loss in penile length (odds ratio: 0.924, 95% confidence interval: 0.878–0.973, P = .0025), whereas increasing body mass index was associated with a loss in perceived penile length (odds ratio: 1.198, 95% confidence interval: 10.53–1.383, P = .0060). Clinical Implications The perception of penile length loss is a commonly held belief in patients after RC, and many patients will perceive losses that exceed 1 inch (2.54 cm). Strengths and Limitations This study is the first series to describe the perception of penile length loss after RC. It is strengthened by the study population's size, heterogeneity, and patient-reported results. It is limited by lack of objective measurements of stretched penile length. Conclusions RC can result in significant sexual dysfunction including the perceived loss of penile length.

Radical cystectomy and urinary diversion remains the gold standard treatment for patients with high risk or muscle invasive bladder cancer. Despite the fact that a majority of patients are eligible for orthotopic neobladder, over 85% of patients receive incontinent urinary diversions, primarily over concerns for complications or postoperative voiding dysfunction. In this review, we explore the incidence, etiology, and treatment of voiding dysfunction after orthotopic neobladder creation in male and female patients. Voiding dysfunction after orthotopic neobladder consists of urinary incontinence and urinary retention. Both are well-recognized potential sequelae, but occur more commonly in female patients. Recent studies have characterized voiding dysfunction as a dynamic problem that improves with time. While treatment options are limited, several techniques exist to minimize the risks of voiding dysfunction after orthotopic neobladder. Despite excellent functional outcomes in the majority of patients, concerns over voiding dysfunction after orthotopic neobladder may in part explain the disparity in receipt of incontinent versus continent urinary diversions. More prospective and patient-reported studies of voiding outcomes are required and newer more effective treatment options for voiding dysfunction are needed.

INTRODUCTION AND OBJECTIVE:Since 2004, multiple drugs have been approved for men with metastatic prostate cancer. Nevertheless, it has been reported that no improvement in survival was observed bet...

INTRODUCTION AND OBJECTIVE:Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functi...

Urothelial carcinoma is one of the most common cancers in the United States, yet outcomes are historically suboptimal. Since 2016, the approval of five programmed cell death 1 and programmed death-ligand 1 immune checkpoint inhibitors for locally advanced and metastatic urothelial carcinoma has led to improved oncologic outcomes for many patients in the second-line setting. Two checkpoint inhibitors, pembrolizumab and atezolizumab subsequently earned approval for first-fine therapy with restricted indications. More recently, pembrolizumab was approved for bacillus Calmette-Guérin-unresponsive high-risk non-muscle invasive bladder cancer, opening the door for other immune checkpoint inhibitors to be integrated into treatment in earlier disease stages. Recent bacillus Calmette-Guérin shortages have highlighted the need for alternative treatment options for patients with non-muscle invasive bladder cancer. Currently, there are no FDA-approved checkpoint inhibitors for non-metastatic muscle-invasive bladder cancer. Furthermore, many patients are ineligible for standard cisplatin-based chemotherapy regimens. Numerous ongoing clinical trials are employing immune checkpoint inhibitors for muscle-invasive bladder cancer patients in the neoadjuvant, adjuvant, perioperative, and bladder-sparing setting. Although up to 10% of urothelial carcinoma tumors arise in the upper urinary tract, few studies are designed for this population. We highlight the need for more trials designed for patients with upper tract disease. Overall, there are numerous clinical trials investigating the safety and efficacy of immune checkpoint inhibitors in all stages of disease as single-agents and combined with dual-immune checkpoint inhibition, chemotherapy, radiotherapy, and other pharmacologic agents. As the field continues to evolve rapidly, we aim to provide an overview of recent and ongoing immunotherapy clinical trials in urothelial carcinoma.

The introduction of cisplatin-based chemotherapy has revolutionized the care of patients with disseminated testicular germ cell tumors. Although a majority are cured with chemotherapy alone, surgical resection continues to play a role because one-third will have residual mass after chemotherapy. In this article, we review the current indications for postchemotherapy resection in nonseminomatous germ cell tumors, including masses greater than 1 cm, resection after salvage chemotherapy, with elevated markers, after late relapse, and for growing teratoma syndrome. We also highlight technical considerations of this often-challenging surgery, including the need for adjunctive procedures, extraretroperitoneal resections, and modern techniques to minimize morbidity.

Objectives To determine the impact of radical cystectomy and orthotopic neobladder (NB) diversion on device-related outcomes in patients who undergo subsequent placement of both, an artificial urinary sphincter (AUS) and 3-piece inflatable penile prosthesis. Materials and Methods Using an institutional prosthetic database, we identified 39 patients who underwent radical cystectomy and NB and subsequent implantation of both prosthetic devices from 2003 to 2017. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection, mechanical failure, revision surgery, and functional outcomes were examined and compared to an appropriate matched group of patients (n = 48, non-neobladder group). Results No intraoperative complications were observed. After median follow-up of 94 months (12-177 months), 1 patient developed an infection of their penile prosthesis and 4 patients developed an erosion of their AUS. In each case, the infection did not involve the other device. Two patients required revision surgery of their penile prosthesis due to mechanical failure (reservoir leak, n = 1; cylinder aneurysm, n = 1). Twenty-one patients underwent elective revision surgery to improve continence (cuff downsizing, n = 18; pressure-regulating balloon exchange, n = 3). There were 6 cases of AUS mechanical failure. No reservoir-related complications such as herniation or erosion were observed. Compared to the control group of non-neobladder patients, there were no significant differences in prosthetic infection, mechanical failure, and revision surgery. Conclusion The AUS and 3-piece inflatable penile prosthesis can coexist safely in patients with NB without an increased risk of device-related complications.

The aim of this study is to evaluate the intra/perioperative fluid management and early postoperative outcomes of patients who underwent radical cystectomy with Enhanced Recovery After Surgery protocol, using goal-directed fluid therapy compared to conventional fluid therapy. This cohort study included patients who underwent open RC for urothelial bladder carcinoma with intent to cure and Enhanced Recovery After Surgery protocol between May 2012 and August 2019. Patients who had palliative or salvage cystectomy and/or adjunct procedures, as well as those with missing detailed perioperative data were excluded. Data were compared between patients who received goal-directed fluid therapy using stroke volume variation by FloTrac™/Vigileo system (n = 119) and conventional fluid therapy based on the anesthesiologist discretion (n = 192). Primary outcome variable was 90-day complications and secondary outcome measures included in-hospital GFR trend, length of stay, and 90-day readmission. The goal-directed fluid therapy group received less total and net intra/perioperative fluid, yet early postoperative glomerular filtration rate trends were similar between both groups (p = 0.7). Estimated blood loss, blood transfusion, index hospital stay, 90-day complication and readmission rates were also comparable between the two groups. Multivariable logistic regression showed no significant association between perioperative fluid management method and 90-day complication rate (OR 1.4, 95% CI 0.8–2.4, p = 0.2). Stroke volume variation guided goal-directed fluid therapy is safe in radical cystectomy without compromising the renal function. It is associated with less intra- and perioperative fluid infusion; however, no association with hospital stay, 90-day complication or readmission rates were noted.

Background Bladder cancer (BC) is the 5th most common cancer in the USA. Non-muscle invasive bladder cancer represents about 70% of all cases and has generally a favorable outcome. However, recurrence rates as high as 60 to 70% and progression rates of 10 to 20% necessitate intensive surveillance with cystoscopy. The invasiveness and high cost of cystoscopy poses significant burden on BC patients as well as on the healthcare system. In this study we test the feasibility of a simple, sensitive, and non-invasive detection of BC using Bladder CARE test in urine samples. Results Urine from 136 healthy and 77 BC subjects was collected using the at-home Bladder CARE Urine Collection Kit and analyzed with Bladder CARE test. The test measures the methylation level of three BC-specific biomarkers and two internal controls using methylation-sensitive restriction enzymes coupled with qPCR. Bladder CARE showed an overall sensitivity of 93.5%, a specificity of 92.6%, and a PPV and NPV of 87.8% and 96.2%, respectively. Bladder CARE has an LOD as low as 0.046%, which equates to detecting 1 cancer cell for every 2,200 cells analyzed. We also provided evidence that bisulfite-free methods to assess DNA methylation, like Bladder CARE, are advantageous compared to conventional methods that rely on bisulfite conversion of the DNA. Conclusion Highly sensitive detection of BC in urine samples is possible using Bladder CARE. The low LOD of the test and the measurement of epigenetic biomarkers make Bladder CARE a good candidate for the early detection of BC and possibly for the routine screening and surveillance of BC patients. Bladder CARE and the at-home urine sample collection system have the potential to (1) reduce unnecessary invasive testing for BC (2) reduce the burden of surveillance on patients and on the healthcare system, (3) improve the detection of early stage BC, and (4) allow physicians to streamline the monitoring of patients.

Objectives To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors. Patients and methods Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion-related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3 catheterisations/day or a self-reported inability to void without a catheter. Uni- and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention. Results Self-catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10 years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10 years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27 kg/m2 ) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26-4.32) as well as retention (HR 5.20, 95% CI 1.74-15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02-3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention. Conclusion In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27 kg/m2 are at significantly increased risk of retention and need for self-catheterisation.

Highlights • COVID-19 has resulted in the delay of elective, possibly curative surgeries for RCC • We examined the oncologic impact of surgical delay in cT1b-T2b RCC • Surgical delays up to 3 months do not increase the risk of pT3a up-staging • Surgical delays up to 3 months do not appear to compromise overall survival • Triaging surgery for RCC should incorporate patient and tumor characteristics, Purpose During COVID-19, many operating rooms were reserved exclusively for emergent cases. As a result, many elective surgeries for renal cell carcinoma (RCC) were deferred, with an unknown impact on outcomes. Since surveillance is commonplace for small renal masses, we focused on larger, organ-confined RCCs. Our primary endpoint was pT3a up-staging and our secondary endpoint was overall survival (OS). Materials and Methods We retrospectively abstracted cT1b-T2bN0M0 RCC patients from the National Cancer Database (NCDB), stratifying them by clinical stage and time from diagnosis to surgery. We selected only those patients who underwent surgery. Patients were grouped by having surgery within 1 month, 1-3 months, or >3 months after diagnosis. Logistic regression models measured pT3a up-staging risk. Kaplan Meier curves and Cox proportional hazards models assessed OS. Results 29,746 patients underwent partial or radical nephrectomy. Delaying surgery >3 months after diagnosis did not confer pT3a up-staging risk among cT1b (OR=0.90; 95%CI: 0.77–1.05, p=0.170), cT2a (OR=0.90; 95%CI: 0.69–1.19, p=0.454), or cT2b (OR=0.96; 95%CI:0.62–1.51, p=0.873). In all clinical stage strata, non-clear cell RCCs were significantly less likely to be up-staged (p6 months, also showed no increase in up-staging risk. Conclusions Delaying surgery up to, and even beyond, 3 months does not significantly increase risk of tumor progression in clinically localized RCC. However, if deciding to delay surgery due to COVID-19, tumor histology, growth kinetics, patient comorbidities, and hospital capacity/resources, should be considered.

INTRODUCTION AND OBJECTIVE:Neoadjuvant chemotherapy provides a survival benefit compared to cystectomy alone in muscle invasive bladder cancer (MIBC), but only in those who respond at least partial...

Leiomyomas are benign mesenchymal neoplasms that originate from smooth muscle cells. Leiomyoma of the testis is exceedlingly rare. We present a case demonstrating a 1.3 cm hypoehoic mass of the left testis but with significant enhancement on contrast-enhanced scrotal ultrasonography concerning for a malignant neoplasm in a 33-year-old Hispanic male. However, his final pathology revealed a benign disease, specifically intratesticular leiomyoma. We discuss the role of contrast-enhanced scrotal ultrasound in this disease process.

The surgical management of disseminated disease has long been an essential component in the management of patients with testis cancer. While the indications for surgery have been narrowed since the advent of cisplatin based chemotherapy, resection remains essential to provide long-term survival. The indications for surgery vary by histology and rely on adequate preoperative imaging to evaluate for residual disease. Surgery for postchemotherapy testis cancer is challenging and requires that surgeons be prepared for extraretroperitoneal resections and adjunctive procedures as necessary. Herein, we review the imaging options that are essential for surgical planning and the various surgical techniques that are often necessary in this challenging situation.

There is no contemporary scoring system to predict hospital length of stay and morbidity in Fournier's gangrene. A retrospective study was conducted to formulate a scoring system to predict duration of hospitalization, resource utilization, need for reconstruction, morbidity and mortality.A retrospective chart review was performed on 54 patients treated for FG from 2010-2016 at LAC+USC Medical Center, the largest public hospital in Los Angeles County. Strobe guidelines were followed and the study was approved by the IRB. Predictors of LOS, morbidity, mortality and resource utilization were identified and univariate linear regressions performed to determine significance. Significant univariate predictors were used to develop a novel scoring system, the Combined Urology and Plastics Index (CUPI). The CUPI score was then compared to existing scoring systems for predicting length of stay.The mean patient age was 49.3, and the mean BMI was 28.6. Patients on average were hospitalized for 37.5 days, with a mean of 8.3 days in the ICU. Three patients (5.6%) died during their hospital stay, and 33 (61%) required reconstructive surgery. Multivariate logistic modeling showed that BMI (p = 0.001) and alkaline phosphatase (p 0.001) correlated with decreasing length of stay, while age at admission was not significantly correlated (p = 0.369). Univariate analysis of existing scoring systems showed that FGSI, LRINEC, NLR, and CCI were not significantly correlated with length of stay, while the newly calculated CUPI score was shown to be a significant predictor of longer hospital stays (p = 0.001).Early emphasis on supportive care, nutrition, and involvement of reconstructive surgeons can decrease LOS in patients with Fournier's gangrene. The CUPI score on admission may be a useful tool for predicting LOS in this population.

To evaluate the association between intraoperative fluid intake and postoperative complications in patients who underwent radical cystectomy (RC) for bladder cancer with an enhanced recovery protocol. 287 patients underwent open RC with enhanced recovery protocol (ERAS) from 2012 to 2016. 107 were excluded; non-urothelial (30), palliative (37), had adjunct procedures or not-consented (40). We prospectively evaluated intraoperative fluid intake (crystalloid, colloid and blood) and correlated with length of stay, 30- and 90-day complications. 180 patients enrolled into the study with median age of 70 years (78% male). 71% underwent orthotopic diversion. Median intraoperative crystalloid and colloid intake were 4000 and 500 cc, respectively. Nineteen percent of patients received blood transfusion. Median length of stay was 4 days. The overall 30- and 90-day complication rates were 59 and 75%, respectively. Multivariate logistic regressions controlling for a subset of clinically relevant variables showed no significant association between intraoperative fluid intake and complications at 30 or 90 days (p = 0.88 and 0.62, respectively). A multivariable linear regression similarly showed no association between total intraoperative fluid intake and length of stay (p = 0.099). Higher intraoperative fluid intake was not found to independently increase the complication rate following radical cystectomy. Larger studies and prospective trials are needed to determine if fluid optimization may play a role in decreasing morbidity after this major surgery.

146 Background: Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functional status. Several oncological guidelines have adopted early integration of PC into oncologic care to improve quality of life among patients with advanced malignancies. However, PC utilization patterns and factors associated with its use in advanced renal cell carcinoma (RCC) remain poorly understood. Methods: Using the National Cancer Database (NCDB), we abstracted patients with Stage III and IV RCC from 2004-2014 and evaluated PC utilization amongst this cohort. Socioeconomic and clinical factors were compared for patient receiving and not receiving PC for advanced RCC. Multivariable logistic regression identified factors that were associated with receipt of PC among the overall cohort and treatment-based cohorts. Results: Among 20,122 and 42,014 patients with Stage III and IV RCC, 329 and 9,317 patients received PC, respectively. From 2004 to 2014, PC utilization was stable at ̃1% for Stage III RCC and minimally increased from 17% to 20% for Stage IV RCC. Multivariable analysis demonstrated that increased comorbidities, insurance status, higher education status, facility location, care at a comprehensive cancer program or integrated network, sarcomatoid histology, and prior treatments significantly increased likelihood of palliative care utilization. We uncover socioeconomic and clinical factors that are associated with receipt of palliative care use in a treatment-specific manner. Conclusions: While PC utilization has minimally increased for Stage IV RCC, there are several demographic, socioeconomic, and clinical factors that predict PC use, especially in a treatment-specific manner, among patients with advanced RCC. Taken together, this suggests the need for more equitable and systematic use of PC among patients with advanced RCC.

77 Background: In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA)-based screening for prostate cancer. Studies have found that insured patients with prostate cancer have better outcomes than uninsured patients. We examined the recommendation’s effects on survival disparities based on insurance status as well as socioeconomic quintile, marital status, and housing (urban/rural). Methods: Using the SEER18 database, we examined prostate cancer-specific survival (PCSS) based on diagnostic time period and one of four factors: insurance status, socioeconomic quintile, marital status, and housing (urban/rural). The SEER-designated socioeconomic quintile was based on variables including median household income and education index. Patients were designated as belonging to the pre-USPSTF era if diagnosed in 2010-2012 or post-USPSTF era if diagnosed in 2014-2016. Disparities were measured with the Cox proportional hazards model. Results: We identified 282,994 patients diagnosed with prostate cancer. During the pre-USPSTF era, uninsured patients experienced worse PCSS compared to insured patients (adjusted HR 1.29, 95% CI 1.06-1.58, p = 0.01). This survival disparity narrowed during the post-USPSTF era as a result of decreased PCSS among insured patients combined with unchanged PCSS among uninsured patients. Moreover, the survival disparity was no longer observed during the post-USPSTF era (aHR 0.91, 95% CI 0.61-1.38, p = 0.67). The survival disparity based on socioeconomic quintile also narrowed but remained significant. In contrast, the survival disparity based on marital status widened, while housing status was not associated with survival disparities in either era. Conclusions: From the pre- to the post-USPSTF era, insured patients with prostate cancer observed a significant decrease in survival that made their survival outcomes similar to that of uninsured patients. Although the underlying reasons are not clear, the USPSTF’s 2012 PSA screening recommendation may have hindered insured patients from being regularly screened for prostate cancer and selectively led to worse outcomes for insured patients without improving the survival of uninsured patients.[Table: see text]

Clear cell renal cell carcinoma is associated with calcium deposition in a significant percentage of patients. However, frank ossification within a tumor is extremely rare. We report a case of a 41-year-old male with a slow-growing left renal mass who underwent minimally invasive nephron-sparing surgery. Final pathology revealed clear cell renal cell carcinoma with focal areas of heterotopic bone formation. While prognostic implications of this variant are unclear, patients with renal cell carcinoma with osseous metaplasia can present with slow growth kinetics and early-stage disease.

To determine if the timing of radical cystectomy for variant histology of urothelial carcinoma has an impact on survival. Variant histology has been associated with aberrant behavior compared to pure urothelial carcinoma, however the timing of surgery for these patients has not been studied.We identified 363 patients with cT2-T4N0M0 urothelial carcinoma who underwent radical cystectomy without perioperative intravesical and/or systemic therapy from 2003 to 2014. Clinicopathologic data were compared between pure urothelial carcinoma and variant histology. The time from diagnosis to radical cystectomy was analyzed as a continuous variable and dichotomized at 4-, 8-, and 12-weeks to determine impact on oncologic outcomes.Patients with variant histology, when compared to those with pure urothelial carcinoma, were more likely to present with extravesical disease (P.01), be upstaged (P.01), have lymphovascular invasion (P.01) and have lymph node metastasis at radical cystectomy (P = .02). The median days to radical cystectomy did not differ between pure urothelial and variant histology. On multivariable analysis controlling for age, comorbidities, tumor stage, lymph node status, lymphovascular invasion, and surgical margins, every month in delay was associated with a worse overall survival for variants (HR = 1.36, P = .003). At an 8-week delay or longer, those with variant histology had a statistically worse survival (P = .03).For patients with variant histology, delays in surgery were associated with an increased risk of death.

INTRODUCTION AND OBJECTIVES:Enhanced Recovery After Surgery (ERAS) protocols have mostly eliminated direct postoperative ICU admission following radical cystectomy (RC) for bladder cancer. However,...

Objective To define clinical features and surgical management of urethro-cavernosal fistulas (UCF). Methods A literature search was performed using PubMed to identify publications with the key word urethro-cavernosal fistula. Results We herein describe surgical techniques and long-term outcomes for UCF repair. Conclusion UCFs is a rare urological condition with only 9 cases reported to date. UCFs can be diagnosed with careful history, physical examination, and retrograde urethrography. Surgical management includes basic tenets of fistula repair, including adequate mobilization, tension-free but watertight approximation, multilayered closure with nonoverlapping suture lines, and maximal bladder drainage.

Our aim is to review recent investigations into the recurrence of urothelial carcinoma in the upper urinary tract following bladder cancer therapy focusing on surveillance and management.After radical cystectomy, rates of recurrence in the upper tract are between 0.75 and 6.4%. The poor prognosis of upper tract urothelial carcinoma (UTUC) is in part attributable to delayed diagnosis. Guidelines recommend a gradual de-escalation of surveillance in disease-free patients with the potential for discontinuation beyond 5 years. Previous guideline audits have shown that recurrences are still missed, suggesting a need for longer follow-up. Studies propose risk stratifying patients by age, comorbidities, and tumor stage to warrant closer surveillance and identify adjuvant therapy candidates. Larger studies are needed to advise treatment of UTUC after a urothelial bladder cancer (UBC) diagnosis, as these patients face poorer outcomes following radical nephroureterectomy. Clinical trials have demonstrated the efficacy of neoadjuvant and adjuvant systemic therapy after radical nephroureterectomy for primary UTUC; however, the literature is lacking robust data on patients who develop urothelial carcinoma in the upper tract following an initial UBC diagnosis.Many asymptomatic recurrences of urothelial carcinoma in the upper tract are undetected by current surveillance guideline recommendations. Higher level evidence is needed to confirm the efficacy of prolonged and risk-adapted surveillance of patients with UBC and the extirpative management of recurrence in the upper tract after UBC treatment.

Bladder cancer is the fourth most common cancer among males and poses a significant financial burden, yet there are no large-scale studies focused on the correlation between socioeconomic (SES) and insurance status and bladder cancer outcomes. The objective of this study was to determine the effect of SES and insurance type on outcomes in bladder cancer.A population-based search was performed using the National Cancer Institute's Surveillance, Epidemiology, and End Results 18 database. Patients aged 18 or older and diagnosed with bladder cancer between 2011 and 2015 were identified. Data on patient demographics, SES features, insurance status, tumor characteristics, and survival were collected. A county-level SES measure was created in a method consistent with prior literature. Primary outcomes were overall survival (OS) and disease-specific survival (DSS).A total of 91,308 patients were identified. Factors predictive of having muscle invasive disease included having Medicaid insurance, having no insurance, and being in the lowest SES quartile (all P0.001). Having Medicaid or no insurance was predictive of having node positive or metastatic disease (P0.001). Independent of T stage, patients in the lowest and second lowest SES quartiles had worse OS (P = 0.004 and P = 0.022, respectively) and DSS (P0.001 for both). Patients with Medicaid or no insurance had worse OS and DSS (P0.001 for all).Lower SES status, Medicaid insurance, and having no insurance were all predictive of having higher tumor stage. Independent of tumor stage, being of lower SES, having Medicaid insurance, and having no insurance predicted worse OS and DSS.

Background Presenting features of inflammatory bowel disease (IBD) are non-specific. We hypothesized that mRNA profiles could (1) identify genes and pathways involved in disease pathogenesis; (2) identify a molecular signature that differentiates IBD from other conditions; (3) provide insight into systemic and colon-specific dysregulation through study of the concordance of the gene expression. Methods Children (8–18 years) were prospectively recruited at the time of diagnostic colonoscopy for possible IBD. We used transcriptome-wide mRNA profiling to study gene expression in colon biopsies and paired whole blood samples. Using blood mRNA measurements, we fit a regression model for disease state prediction that was validated in an independent test set of adult subjects (GSE3365). Results Ninety-eight children were recruited [39 Crohn’s disease, 18 ulcerative colitis, 2 IBDU, 39 non-IBD]. There were 1,118 significantly differentially (IBD vs non-IBD) expressed genes in colon tissue, and 880 in blood. The direction of relative change in expression was concordant for 106/112 genes differentially expressed in both tissue types. The regression model from the blood mRNA measurements distinguished IBD vs non-IBD disease status in the independent test set with 80% accuracy using only 6 genes. The overlap of 5 immune and metabolic pathways in the two tissue types was significant (p

To evaluate pathologic downstaging after radical cystectomy and pelvic lymph node dissection for clinically lymph node positive urothelial bladder cancer and to determine optimal preoperative imaging variables in predicting pathologic nodal status.We identified all patients with clinically lymph node positive urothelial bladder cancer who underwent radical cystectomy and extended pelvic lymph node dissection with intent to cure at our institution. Patients were stratified based on pathologic node status to determine clinical associations and survival outcomes. Pre and post-chemotherapy CT scans were reviewed to characterize lymph node size and morphology. We also sought to determine associations between post-chemotherapy radiology variables and pathologic response.We identified 130 patients with clinically node positive bladder cancer, out of which 76 (58.5%) received induction chemotherapy. Thirty three (43.4%) had pathologic T downstaging following chemotherapy, compared to 7 (12.9%) patients who had surgery alone (P0.0001). A complete nodal response (pN0) occurred in 31 (40.8%) patients post-chemotherapy, while 6 (11.1%) of those who received cystectomy alone ended up being pN0 (P0.0001). Median overall survival and recurrence-free survival were shorter in patients with pN+ versus pN0 disease (1.9 years vs. 12.8 years, P= 0.016 and 1.2 years vs. 4.3 years, P= 0.013, respectively). Review of 29 post chemotherapy CT scans showed that patients with pathologic nodal involvement had a greater median number of enlarged nodes (3.5 vs. 1, P= 0.038) and a greater median size of largest node (8.5 mm vs. 6.0 mm, P= 0.021) on imaging compared to those with complete pN0. Each 1 mm increase in size of the largest node on post-chemotherapy CT scan increased the chance of having pN+ disease by 1.57 (95% CI 1.02-2.44, P= 0.043). Using a median node size of 8 mm as a cut-off to predict pN+ disease provided a sensitivity and specificity of 72% and 80%, respectively (c-index = 0.761, P= 0.014). The positive predictive value for this cut-off was 87% (95% CI 58%-98%) and negative predictive value was 62% (32%-85%).Patients with clinically node positive bladder cancer may have significant pN0 after induction chemotherapy. Our data suggest a post-chemotherapy CT scan with an 8 mm nodal size cut-off may be a better predictor of pathologic nodal status than more traditional measures.

The purpose of the study is to review and summarize major additions to the literature as pertains to enhanced recovery protocols after radical cystectomy in the past year. Enhanced recovery after surgery protocols is multimodal pathways that include elements to optimize all stages of care including preoperative, intraoperative and postoperative measures. Several authors have recently presented their results with initial implementation of an enhanced recovery protocol after radical cystectomy, while others have begun to examine outcomes beyond the index admission and to refine the various targeted components of the protocol. Enhanced recovery after surgery protocols has revolutionized patient care following radical cystectomy, a procedure still burdened by high complication rates and lengthy hospital stay. Although still lacking in universal implementation and standardization of the protocol, significant advancements are made each year as we move towards best practice.

To determine and investigate the intraoperative factors that contribute to a change in plan from continent orthotopic neobladder to ileal conduit or continent cutaneous diversion at the time of radical cystectomy. A retrospective review of our prospectively maintained bladder cancer database was performed. Of the 711 patients who underwent radical cystectomy from 2012 to 2016, 387 (54.4%) had given consent to have a NB. Of these 387 patients, 348 (89.9%) ultimately received a neobladder while 34 (8.8%) received an ileal conduit and 5 (1.3%) continent cutaneous diversion. The factors involved in the intraoperative change of plan were examined in this study. Patients who ultimately received a neobladder were significantly more likely to have clinical node-negative disease (p = 0.045), negative soft tissue margins (p = 0.001), lower body mass index (p = 0.045) and higher volume surgeons (p

Significant evidence exists regarding the diagnostic and therapeutic roles of pelvic lymph node dissection at the time of radical cystectomy for patients with bladder cancer. Despite this, lymphadenectomy for bladder cancer is still underutilized and even where performed, controversies exist in regard to what defines an adequate dissection and whether or not the indications for lymphadenectomy have changed now that we are firmly entrenched in the neoadjuvant chemotherapy era. A comprehensive literature review was performed to touch on these important issues and highlight future directions and current trials that will soon provide more clarity for surgeons and patients dealing with bladder cancer.

Paratesticular serous papillary carcinomas are very rare, with less than 40 cases reported in the literature. These neoplasms are Mullerian in origin, and more commonly seen as epithelial-type ovarian cancer. Given the rarity of this tumor in men, staging and recommended treatment options do not exist. Herein, we present the case of a 35-year-old male with high-grade invasive serous papillary carcinoma. He was diagnosed after left radical orchiectomy for paratesticular mass and subsequently treated with adjuvant chemotherapy according to existing recommendations for its ovarian counterpart. Chemotherapy was well tolerated and surveillance imaging has shown no evidence of disease. This case suggests a potential role for adjuvant therapy in patients with high-grade paratesticular serous papillary carcinoma.

Acute lung injury following lower torso ischemia-reperfusion has been described, typically from the lower limbs. We present a case of acute respiratory failure following removal of a metal ring from an ischemic penis.

563 Background: In metastatic nonseminomatous testicular germ cell tumor (NSGCT), post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is indicated for residual masses > 1 cm because of these 45% will be fibrosis/necrosis, 45% will be teratoma and 15% will be viable malignancy. There is no imaging test that reliably distinguishes lymph nodes (LNs) with tumor (teratoma or malignancy) from LNs with fibrosis/necrosis. We evaluated whether quantitative CT texture analysis (TA) could make this differentiation. Methods: Pre- and post-chemotherapy CTs (all same phase and slice thickness) were reviewed in 22 NSGCT patients with RP LNs > 1 cm post chemotherapy. After manual segmentation of RP LNs on a 3D workstation, 187 TA metrics were derived, using 2D/3D gray-level co-occurrence matrix (GLCM), 2D/3D gray-level difference matrix (GLDM), and spectral analysis. Metrics were derived 2 ways: from post-chemotherapy CTs alone, and also as a difference between pre- and post-chemotherapy CTs, resulting in 374 metrics. PC-RPLND pathology was correlated with CT data at 88 LN stations in these 22 patients. Results: 15 imaging metrics showed a significant difference (p ≤ 0.05) between LN stations with only fibrosis/necrosis and those with teratoma or viable tumor. Seven were derived from the difference between pre- and post-chemotherapy CTs: 4 using a 2D GLCM (coronal standard deviation, coronal square root of variance, coronal mean, and coronal sum of average), and 3 using a 2D GLDM (axial variance, axial square root of variance, and coronal variance). The other 8 were derived from post-chemotherapy CTs alone: 7 using a 2D GLCM (sagittal square root of variance, sagittal standard deviation, coronal square root of variance, coronal mean, coronal standard deviation, coronal sum of average, and coronal entropy) and 1 using a 2D GLDM (sagittal sum entropy). Conclusions: CT TA shows promise in differentiating necrosis from teratoma or viable tumor in RP LNs in post-chemotherapy NSGCT. A larger study is needed to further test this method, towards a long-term goal of potentially allowing some patients to avoid PC-RPLND.

503 Background: Neoadjuvant chemotherapy (NAC) improves overall survival (OS) for patients with muscle invasive bladder cancer (MIBC) undergoing radical cystectomy (RC), possibly through an increase in pathologic complete response (CR), defined as a pathologic stage T0 (pT0). We sought to identify predictors of CR for MIBC. Methods: The National Cancer Database from 2004 to 2013 was used to identify patients with cT2-4cN0cM0 urothelial cell carcinoma treated with RC. Patients were grouped based on pathology as CR (pT0), partial response (PR – pTa/Tis/T1) or no response (NR - pT2 or higher). Predictors of NAC and CR were identified with multivariable logistic regression. Cox proportional hazards model was used to compare OS based on cT stage, receipt of NAC and pathologic response. Results: The study population included 10,820 patients and NAC was administered in 16.4%. Use of NAC was associated with higher cT stage (p < 0.01) and increased over time (10% from 2003-2007 vs. 24% from 2011-2013, p < 0.01). Predictors of NAC use on multivariable analysis include younger age, lower comorbidity score, treatment at an academic center, and diagnosis from 2011-2013 (p < 0.01). Overall, CR was achieved in 3.3% without NAC and 16.3% with NAC (p < 0.01). NAC improved 5-year OS for all cT stages, however the survival benefit was only observed among those achieving CR (p < 0.01). Multivariable Cox regression demonstrates that both PR (HR 0. 58, p < 0.01) and CR (OR 0.26, p < 0.01) were independently associated with improved OS among those treated with NAC. Multivariable analysis identified age (OR 0.98, p < 0.01) and increased clinical stage (cT3: OR 0.47, p < 0.01; cT4 OR 0.54, p < 0.01) as negative predictors of CR. Utilization of NAC (OR 4.82 p < 0.01), academic institution, and diagnosis 2011-2013 (OR 1.92, p < 0.01) increased the odds of CR. Conclusions: Use of NAC increased over time and CR occurred in 16% of patients who received NAC. Treatment at an academic center, diagnosis from 2011-2013 and use of NAC were independently associated with CR, while increased age and clinical stage were negative predictors of CR. PR and CR are independently associated with improved OS relative to non-responders.

INTRODUCTION AND OBJECTIVES: With increasing incidental renal tumor detection, rates of renal surgery in the elderly and infirmed are rising. Our aim was to examine the association between high risk patient status (age 75 years and/or Charlson comorbidity [CCI] count 2) and post-operative complications in patients undergoing surgical management for clinically localized renal tumors. METHODS: We queried our prospectively maintained institutional database to identify all patients undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for clinical stage I-II renal tumors from 2005-2012. Post-operative complications within 90 days were categorized by the Clavien-Dindo classification system. Univariate and multivariate logistic regression models were used to test the association between high risk status and post-operative complications adjusting for patient (risk group, gender, race), tumor (Nephrometry Score [NS], hilar designation, solitary kidney), and operative (year of surgery, nephron sparing and minimally invasive approaches, blood loss, operative time) characteristics. RESULTS: 1,092 patients (mean age 59.2 11.9 years, 64.2% male, mean CCI count 1.3 1.6) undergoing PN (71.9%) or RN (28.1%) for clinically localized renal tumors (mean tumor size 4.2 2.9cm, mean NS 7.8 2.0) met inclusion criteria. 255 (23.4%) patients were classified as high risk; of these, 175 (16%) incurred one or more complications (mean 1.6 1.0). High risk patients were more likely to experience a complication compared to those classified as low risk (22.4 versus 14.1%; p 0.002). Comparing high and low risk patients, significant differences in Clavien I-II (20.4 vs. 11.1%; p 0.001) and medical (16.1 vs. 8.1%, p 0.001) complications were observed, while no differences were seen in Clavien III-IV or surgical complications. Further, no differences in complications were observed comparing patients treated with RN and PN, albeit high risk patients were more likely to undergo RN (35.3 vs. 25.9%, p 0.04). Following adjustment, the odds of incurring any complication were 1.9 times higher in high compared to low risk patients (OR 1.9 [CI 1.3-2.8]). CONCLUSIONS: In our cohort, patients deemed high risk by age and comorbidity criteria were more likely to incur a complication following renal surgery regardless of surgical type. Improved understanding of surgical risks in the elderly and infirmed will better inform patients deciding between active surveillance and resection of localized renal tumors.